目的:探讨社区卫生服务中心对高血压患者实施团队式健康管理的效果.方法:选取北外及万寿山庄辖区内原发性高血压患者500例为研究对象,一级管理组229人;二级管理组206人:三级管理组65人;根据管理前后高血压患者知晓率、血压控制率、服药依从性、血脂改变,不良生活方式改变等情况.来评价管理的效果.结果:三组级别高血压年度管理评估及临床评估对比变化与管理前比较,差异有统计学意义(P<0.01);高血压患者规范化管理后优良率年度评估明显提高、尚可率、不良率明显降低,差异有统计学意义(P<0.01);高血压患者管理前后血脂生化检测,总胆固醇、低密度脂蛋白指标较管理前均有明显改善,差异有统计学意义(P<0.01),但高密度脂蛋白、三酰甘油、体重指数无明显变化(P>0.05);管理后高血压患者的生活方式均有明显改善,与之前比较差异有统计学意义(P<0.01).结论:以社区团队模式开展对高血压患者进行健康管理,可有效控制患者血压,降低危险因素,对患者的知、信、行及治疗是有效的管理模式.%Objective: To study the community health service centers for patients with hypertension the effect of team-style health management.Methods: North Hills area outside and Longevity in patients with essential hypertension as a study of 500 cases, a management group of 229 people; second management group of 206 people; level management group 65; under the management of hypertensive patients before and after the awareness, blood pressure control rates, medication compliance, blood lipid changes, lifestyle changes, etc., to evaluate management effectiveness.Results: The annual management assessment of group-level blood pressure compared with changes in clinical assessment, and management before there was significant difference (P＜0.01); standardized management of patients with hypertension after the fine was increased compared with the annual assessment rate, fair rate, poor rate decreased, the difference was statistically significant (P＜0.01); management of patients with hypertension before and after the blood biochemical test, total cholesterol, low density lipopro-tein indicators were significantly improved compared with before administration, the difference was statistically significant (P＜0.01), However, the high-density lipoprotein, triglycerides, no significant changes in body mass index (P＞0.05); manage ment of patients with hypertension after life were significantly improved compared with the previous difference was statistically significant (P＜0.01).Conclusion: The model of community groups to carry out health management of hypertensive patients, can effectively control blood pressure, reduce risk factors, knowledge of the patient, believing, and treatment is effective management.
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